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FORM #563GC (2/2004) SCPC administrative STATE OF SOUTH CAROLINA ) ) IN THE PROBATE COURT COUNTY OF ) ) RECEIPT IN THE MATTER OF: ) ) CASE NUMBER The undersigned hereby acknowledge receipt from the conservator in this matter of the following property: Executed this day of , 20 . Witness: Recipient: American LegalNet, Inc. www.FormsWorkFlow.com